Cyclic Vomiting Syndrome Research Articles

Clinical Characteristics of Pediatric Patients with Cyclic Vomiting Syndrome in Southern Iran`

Introduction: Cyclic vomiting syndrome (CVS) is characterized by recurrent episodes of intense nausea and vomiting interpreted with symptom free period. As data regarding the pattern of disease in our region is scarce, we performed this study to investigate the pattern of pediatric cyclic vomiting in Shiraz, southern Iran. Methods and Patients: This study was performed in Nemazee Hospital, territory health care center affiliated with Shiraz University of Medical Sciences from 2000 to 2010. Medical files were reviewed and data was collected by means of a checklist. Patients were divided into two groups including 1-13 years of age as children and those 13-18 years of age as adolescents. Results: Overall, 43 patients with CVS were included, among whom there were 26 (60.5%) females. The mean age at first attack was found to be 6.2 (3.7) years. Ten patients (23.3%) had a family history of migraine among which there were 8 females. The most common clinical complaint was found to be abdominal pain in 32 (74.4%) patients. GI (gastrointestinal) disorders were more common in the adolescent group rather than the children group (p=0.007).The most common trigger factor was upper respiratory tract infection (URI) detected in 13 patients (30.2%).The most associated disorder was abdominal migraine in 5 (11.6%) patients. Anemia was more common in the adolescent group (p=0.009) than in the children’s group .There were no radiological and laboratory abnormalities among these patients. The most commonly used medications were anti-migraines in 31 (72.0%) patients.Conclusion: as there is no definite drug for CVS, knowing the common trigger factors which culminate in CVS in each region can be of great importance and can prevent attacks in the prodromal phase. [GMJ. 2012;1(1):29-34]

1496 When Suspect Panayiotopoulos Syndrome (PS) In a Child with Clinical Diagnosis of Gastric Esophagus Reflux Disease (Gerd)

Panayiotopoulos syndrome is “a benign age related focal seizure disorder occurring in early and mid-childhood. It is characterized by seizures, often prolonged, with predominantly autonomic symptoms, and by an EEG...

Identification and Successful Treatment of Gastric Dysrhythmia Associated with Cyclic Vomiting Syndrome: A Case Report

Identification and Successful Treatment of Gastric Dysrhythmia Associated with Cyclic Vomiting Syndrome: A Case Report

1686 Review of Cyclical Vomiting Syndrome in a General Paediatric Hospital over a 12 Year Period

Background and AimsCyclical vomiting syndrome (CVS) is a chronic disorder characterised by recurrent episodes of vomiting separated by symptom free periods. Aim is to review the epidemiology, history, investigation and...

The management of cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children. It is a frequently missed diagnosis in the emergency department and may require a number of emergency department visits before the diagnosis is made. The objectives of this review are to identify the clinical features that suggest a diagnosis of CVS and to review the literature on its management. The MEDLINE and EMBASE databases were searched from January 1948 to October 2011 using the keywords 'Cyclic' or 'Vomiting'. Papers were excluded if they did not follow the consensus guidelines or if they were case reports. This review analysed 1093 cases of cyclic vomiting in 25 papers that fulfilled the inclusion criteria. All except one paper were retrospective studies. The size of these cohort studies ranged from three to 181 patients, with a mean patient size of 29. This review found that over 40% of patients have headaches/migraines, with associated anxiety and depression in ≈ 30% of cases. There is a family history of headaches/migraines in 38.9%, and this association was much stronger in the adult CVS cohort compared with the paediatric cohort. Compared with paediatric CVS, adults have a longer duration of attacks and they occur more frequently (5.9 vs. 3.4 days, 14.4 vs. 9.6 episodes/year). Limited data are available on the treatment of the acute phase of CVS, but in adults, sumatriptan has been shown to be effective. For prophylactic treatment, tricyclics are effective in both adult and paediatric CVS, with a clinical response in 75.5 and 67.6% of patients, respectively, in nonplacebo-controlled cohort studies. Furthermore, propranolol has been shown to be useful in children. CVS is an intractable illness with a major impact on the patient's quality of life. There is a long duration between the onset of symptoms and the diagnosis of the condition. There is a high association with headaches/migraines and anxiety/depression. The symptoms are more severe in adult-onset CVS. Tricyclic antidepressants have good efficacy in reducing the frequency/duration or the intensity of attacks. There is limited evidence on the acute management of CVS.

Cyclic vomiting syndrome in 28 patients

Cyclic vomiting syndrome (CVS) is a condition characterized by recurrent, stereotyped, attacks of intense nausea and intractable vomiting with no identifiable cause. The diagnosis is made according to the Rome III criteria; however, the condition remains a heterogenous group of symptoms and few studies have analysed patient-reported features in detail. Tricyclic antidepressants may benefit some patients, but there are no data on the long-term outcomes of this condition. This is a retrospective cohort study of all patients treated at two London teaching hospitals between 1994 and 2011. Information was obtained by means of inpatient case notes, clinic letters and telephone interviews using a standardized questionnaire. Twenty-eight patients were identified, 17 with adult-onset CVS and 11 with childhood-onset CVS. In the adult-onset CVS cohort, the average age of onset was 30 years; the prevalence of headache was 57.1% and anxiety/depression 21.7%. Vomiting attacks occurred on average 10 times a year with a mean duration of 55.3 h. In the childhood-onset CVS cohort, the average age of onset was 5 years and the prevalence of headaches was 44.4%. Vomiting attacks occurred on average 25.5 times a year with a mean duration of 54.5 h. During acute attacks, patients rated morphine-based medications as the most efficacious. Overall, 65.4% of our patients were not treated with long-term prophylactic medications and, of these, 42.1% felt that their symptoms had improved and 26.3% reported complete resolution. CVS is a debilitating illness with frequent attacks of prolonged duration. There is a high association with anxiety/depression as well as headaches. Antimigraine medication, β-blockers and antiepileptic treatment may be successful at attenuating attacks; however, in this long-term study, the prognosis of patients not treated with these medications was also good. Overall, 61.9% of patients showed a gradual improvement in symptoms and 23.8% had complete resolution after a mean of 7 years.

Cyclical vomiting syndrome in children: a prospective study

Cyclical vomiting syndrome (CVS) is a disorder that affects all ages and is characterized by episodes of severe nausea and vomiting with symptom-free intervals between episodes. The incidence in children is 3.15/100 000 children per year. Our objective was to evaluate the natural history of CVS and examine factors that predict symptom resolution. Thirty newly diagnosed children (mean 9.15 years, SD 3.31 range 3.5-15.7) were enrolled. All children had a follow-up interview at 3 months, 27/30 at 6 months, and 22/30 at 9 months. Following diagnosis of CVS, only 5/22(22.7%) children had no further episodes of vomiting at 9 months, whereas 17/22 (77.3%) continued to vomit. In the year prior to diagnosis, 15/30 (50%) children were admitted to hospital. Of the 22 children with follow-up for 9 months, only one child required hospital admission. Children who continued to vomit had higher internalizing scores on CBCL compared with those who stopped vomiting (P = NS). The Pediatric Quality-of-Life Score suggested those who continued to vomit had a poorer quality of life at diagnosis compared with those who stopped vomiting (P < 0.05). Making a positive diagnosis of CVS and providing families with information is very important in the management of CVS. Although 75% of children reported regular episodes of vomiting 9 months after diagnosis, there was a significant reduction in the frequency and severity of symptoms in addition to a marked reduction in the use of medical services.

Zyklisches Erbrechenssyndrom (CVS) beim Erwachsenen - eine häufig übersehene Erkrankung?

CVS (cyclic vomiting syndrome) is a functional disorder that can occur in all age groups. Adults typically develop CVS in middle age (around the 35th year of life). CVS is characterised by recurrent stereotypic episodes of nausea and vomiting lasting hours or some days. Between these episodes there are intervals free of symptoms. The main symptoms include nausea, vomiting and often abdominal pain. CVS is a rare disorder in adult patients. Because of the lack of awarness, making the correct diagnosis is not easy und often delayed for some months or years. There is no specific test to secure the diagnosis. The accurate diagnosis is based on the typical anamnestic report and the exclusion of other disorders associated with a recurrent vomiting. No standard evidence-based treatment is currently available either to manage the acute vomiting episode or to manage the prophylactic therapy. For the acute treatment of the vomiting episodes antiemetic, antimigraine and sedative medications were used. The medications frequently used for the prophylactic therapy are amitriptyline and propranolol.

Association of Marijuana Use and Cyclic Vomiting Syndrome

Cannabis use has become one of the most commonly abused drugs in the world. It is estimated that each year 2.6 million individuals in the USA become new users and most are younger than 19 years of age. Reports describe marijuana use as high as 40–50% in male Cyclic Vomiting Syndrome patients. It is this interest in cannabis in the World, coupled with recognition of a cyclic vomiting illness associated with its chronic use that beckons a review of the most current articles, as well as a contribution from our own experiences in this area. The similarities we have demonstrated for both cannibinoid hyperemesis syndrome and cyclic vomiting make the case that cannibinoid hyperemesis syndrome is a subset of patients who have the diagnoses of cyclic vomiting syndrome and the role of marijuana should always be considered in the diagnosis of CVS, particularly in males.

Cyclic Vomiting Syndrome (CVS): is there a difference based on onset of symptoms - pediatric versus adult?

BackgroundCyclic Vomiting Syndrome (CVS) is a well-recognized functional gastrointestinal disorder in children but its presentation is poorly understood in adults. Genetic differences in pediatric-onset (presentation before age 18) and adult-onset CVS have been reported recently but their clinical features and possible differences in response to therapy have not been well studied.MethodsThis was a retrospective review of 101 CVS patients seen at the Medical College of Wisconsin between 2006 and 2008. Rome III criteria were utilized to make the diagnosis of CVS.ResultsOur study population comprised of 29(29%) pediatric-onset and 72 (71%) adult-onset CVS patients. Pediatric-onset CVS patients were more likely to be female (86% vs. 57%, p = 0.005) and had a higher prevalence of CVS plus (CVS + neurocognitive disorders) as compared to adult-onset CVS patients (14% vs. 3%, p = 0.05). There was a longer delay in diagnosis (10 ± 7 years) in the pediatric-onset group when compared to (5 ± 7 years) adult-onset CVS group (p = 0.001). Chronic opiate use was less frequent in the pediatric-onset group compared to adult-onset patients (0% vs. 23%, p = 0.004). Aside from these differences, the two groups were similar with regards to their clinical features and the time of onset of symptoms did not predict response to standard treatment. The majority of patients (86%) responded to treatment with tricyclic antidepressants, anticonvulsants (topiramate), coenzyme Q-10, and L-carnitine. Non-response to therapy was associated with coalescence of symptoms, chronic opiate use and more severe disease as characterized by longer episodes, greater number of emergency department visits in the year prior to presentation, presence of disability and non-compliance on univariate analysis. On multivariate analysis, only compliance to therapy was associated with a response. (88% vs. 38%, Odds Ratio, OR 9.6; 95% Confidence Interval [CI], 1.18-77.05).ConclusionDespite reported genetic differences, the clinical features and response to standard therapy in pediatric- and adult-onset CVS were mostly similar. Most patients (86%) responded to therapy and compliance was the only factor associated with a response.

PWE-053 Cyclic vomiting syndrome in 28 patients: demographics, features and outcomes

IntroductionCyclic Vomiting syndrome (CVS) is a condition characterised by recurrent, stereotyped attacks of intense nausea and intractable vomiting with no identifiable organic cause. The diagnosis of CVS has been helped...

PWE-054 The management of cyclic vomiting syndrome: a systematic review of 1141 cases

IntroductionCyclic Vomiting syndrome (CVS) is characterised by recurrent attacks of intractable vomiting with no identifiable organic cause. It can take years before CVS is diagnosed, furthermore there have only been...

Antimigraine (Low‐Amine) Diet May Be Helpful in Children With Cyclic Vomiting Syndrome

To the Editor: Cyclic vomiting syndrome (CVS) is considered to be a functional gastrointestinal disorder characterised by stereotypical episodes of acute vomiting lasting <1 week with ≥3 discrete episodes in the previous year and absence of nausea and vomiting between the episodes. CVS has been managed with antiemetics and intravenous fluids with reasonable success (1,2). CVS is increasingly being recognised as a brain–gut disorder and has been associated with a high familial prevalence of migraine or considered to be a migraine variant in children (2,3). As with migraine, CVS has been associated with the ingestion of foods such as cheese, chocolate, citrus fruits, caffeine, yeast extract, and pork (2). A study in Italy showed improvement with the exclusion diet in CVS symptoms in 7 of 8 children. These children showed positive skin prick tests and specific immunoglobulin E to cow's-milk protein, egg whites, and soya; however, there was no history of specific food allergies (4). We describe a low-amine diet (LAD) as prophylactic therapy for CVS, which avoids all of the food groups previously implicated as migraine triggers (5). The food groups that need to be avoided include cheese, chocolate, citrus fruit and their juices, pork and pork products, peas, broad beans, game, shellfish, yeast extract, beef extract, gravies, drinks containing caffeine (tea, coffee, cola-based drinks), and alcohol (5). The single-centre cohort consisted of 21 children (9 girls [43%]) between 2 and 16 years who presented to the paediatric gastroenterology clinic with recurrent stereotypic episodes of frequent vomiting. A total of 17 children (81%) were reported as having abdominal pain and 6 children (29%) had nausea during the episodes. A total of 16 children (76%) came from families with a strong history of migraine. These children remained symptom free between the episodes. The rationale of LAD and expected benefits were discussed by a paediatric dietitian with the family before starting the therapy, which was continued for a minimum of 6 to 8 weeks. If adverse effects such as worsening of frequency or severity of vomiting or abdominal pain were noted, then the therapy was stopped earlier. A total of 18 children (86%) responded to the LAD therapy and the results are shown in Figure 1. In the group of children who had complete resolution of vomiting, 2 of 13 children continued to have abdominal pain and 1 child developed migraine symptoms later. In the 5 children who showed partial resolution of symptoms, the episodes of CVS were less frequent, less severe, and of shorter duration. Our preliminary findings suggest that LAD may be useful in some children with CVS.FIGURE 1: Response to low-amine diet on vomiting.

Sa1425 Assessment of White Matter Tract Integrity of Brain in Cyclic Vomiting Syndrome by Diffusion Tensor Imaging

Sa1425 Assessment of White Matter Tract Integrity of Brain in Cyclic Vomiting Syndrome by Diffusion Tensor Imaging

Su1982 Cyclic Vomiting Syndrome is Associated With Alterations of Brain Connectivity

Su1982 Cyclic Vomiting Syndrome is Associated With Alterations of Brain Connectivity

Su1974 Classification of Cyclic Vomiting Syndrome Patients in Inter-Episodic Phase From Healthy Controls Using Cortical Resting State Functional Connectivity

Background/Aims: Anecdotal clinical evidence supports the use of carbonated liquids in reducing the likelihood of aspiration in dysphagic patients (Bulow et al,Acta Radiol 2003; Sdravou et al, Dysphagia 2011). Repetitive transcranial magnetic stimulation (rTMS) delivered at 1-Hz can induce transient focal suppression of pharyngeal motor cortex (Mistry S., et al. J Physiol, 2007). Here we investigated whether swallowing of carbonated water can reverse the inhibitory effects of a virtual lesion to pharyngeal motor cortex, compared to still water and saliva swallowing. Methods: In 9 healthy subjects (5 male, mean age 33.7 ± 14.34(SD)) pharyngeal electromyographic responses were recorded using an intraluminal catheter after the application of Transcranial Magnetic Stimulation (TMS) over pharyngeal motor cortex, as a measure of cortico-bulbar excitability. On 3 randomised visits, subjects were cued by a visual feedback software to perform a total of 40 swallows over 10 minutes (swallows every 15 s) of either carbonated water or still water vs. 10 minutes of saliva swallowing ad libitum (control), before and after an unilateral 1-Hz virtual lesion of the pharyngeal motor cortex. Cortical excitability (presented as mean ± SEM) was then reassessed bilaterally for 60 minutes post-interventions and analysed with two-way ANOVA (SPSS 14). Results: Compared to saliva swallowing (control), swallowing of carbonated water appeared to increase cortical excitability bilaterally (lesioned pharyngeal motor cortex: 68 ± 38% at 30 minutes post intervention, and to the unlesioned: 60 ± 24%, at 15 minutes post), not seen with still water swallowing. However, using a 2-way ANOVA, only the effects over the ipsilateral (lesioned) pharyngeal motor projection were statistical significant for carbonation (F1,8=6.2, p=0.037, Figure 1). Conclusion: Carbonation reverses the effects of a unilateral virtual lesion with significant increases in cortical excitability limited to the lesioned hemisphere. These data support the notion that chemesthetic solutions of carbonation may provide the required peripheral sensory information that can influence greater neuronal activity compared to still water swallowing. These data provides the platform for considering the use of carbonation as facilitating stimuli in dysphagic patients who aspirate thin liquids.

Tu1486 Towards a Wellness Index for Motility Disorders: the use of Desirability Functions to Evaluate Health Status in Patients With Gastroparesis

G A A b st ra ct s research. Oral domperidone has been reported in some cases to prolong the QT interval and predispose to ventricular arrhythmias (Reddymasu et al. Am J Gastro 2007;102:20362045). The aims: 1) To establish an indications and clinical profile of patients receiving domperidone through the limited access protocol 2) to investigate possible side effects of domperidone 3) to analyze ECG reports and the duration of QT intervals. Methods: Study involved a retrospective chart review of 163 patients referred to a single physician at the tertiary GI Motility Center. Patients demographics, GI diagnosis, cardiovascular complain and ECG tracings were obtained. Prolonged QTc were verified if they were longer than 470 ms in females and longer than 450 ms in male patients. Results: Overall 23 out of 163 (13%) patients (15 F; mean age 47, range 18-73) presenting with chief complaints of nausea and vomiting were enrolled in FDA approved protocol and received doses of domperidone ranging from 10 to 30mg QID for at least 6 up to 12 months. 8 (36%) patients were Hispanic, 12 (52%) Caucasian, and 3(12%) African American. A total 16 (60%) of these patients (9F) were diagnosed with GP, 4 females met the criteria for Cyclic Vomiting Syndrome and 3 patients had symptoms of unexplained nausea. 6 (27%) ECG reports showed non-significant sinus arrhythmias, and one male patient had an irregular rhythm. Women had mean heart rates of 82 (range 52-112) and men's average HR was 86 (range 55-105) bpm. Overall the mean value of QTc for all domperidone patients was 427 ms (ranges 383 507 ms). Further analysis of ECGs for females showed, mean QTc duration of 425 (394-507) ms and in males it was 429 (383-469) ms. Two patients (9%), one of each gender, had QTc prolongation above the normal respected value. No patients complained about palpitation or cardiac/ chest pain. Two patients noticed breast discomfort. No other potential adverse events including extra-pyramidal side effects were reported during this investigation. Conclusions:1) Domperidone is legally available in USA under the FDAIND approved protocol and can be prescribed for patients with symptoms of nausea and vomiting related to gastroparesis and other motility disorders 2) No clinically relevant cardiac complaints and ECG changes including QTc prolongations were discovered during this observation 3) Domperidone can be regarded as a safe prokinetic and antiemetic agent.

Tu1487 Progressive Occlusion of Mesenteric Artery Changes Biomagnetic Signature of Intestinal Slow Wave

G A A b st ra ct s research. Oral domperidone has been reported in some cases to prolong the QT interval and predispose to ventricular arrhythmias (Reddymasu et al. Am J Gastro 2007;102:20362045). The aims: 1) To establish an indications and clinical profile of patients receiving domperidone through the limited access protocol 2) to investigate possible side effects of domperidone 3) to analyze ECG reports and the duration of QT intervals. Methods: Study involved a retrospective chart review of 163 patients referred to a single physician at the tertiary GI Motility Center. Patients demographics, GI diagnosis, cardiovascular complain and ECG tracings were obtained. Prolonged QTc were verified if they were longer than 470 ms in females and longer than 450 ms in male patients. Results: Overall 23 out of 163 (13%) patients (15 F; mean age 47, range 18-73) presenting with chief complaints of nausea and vomiting were enrolled in FDA approved protocol and received doses of domperidone ranging from 10 to 30mg QID for at least 6 up to 12 months. 8 (36%) patients were Hispanic, 12 (52%) Caucasian, and 3(12%) African American. A total 16 (60%) of these patients (9F) were diagnosed with GP, 4 females met the criteria for Cyclic Vomiting Syndrome and 3 patients had symptoms of unexplained nausea. 6 (27%) ECG reports showed non-significant sinus arrhythmias, and one male patient had an irregular rhythm. Women had mean heart rates of 82 (range 52-112) and men's average HR was 86 (range 55-105) bpm. Overall the mean value of QTc for all domperidone patients was 427 ms (ranges 383 507 ms). Further analysis of ECGs for females showed, mean QTc duration of 425 (394-507) ms and in males it was 429 (383-469) ms. Two patients (9%), one of each gender, had QTc prolongation above the normal respected value. No patients complained about palpitation or cardiac/ chest pain. Two patients noticed breast discomfort. No other potential adverse events including extra-pyramidal side effects were reported during this investigation. Conclusions:1) Domperidone is legally available in USA under the FDAIND approved protocol and can be prescribed for patients with symptoms of nausea and vomiting related to gastroparesis and other motility disorders 2) No clinically relevant cardiac complaints and ECG changes including QTc prolongations were discovered during this observation 3) Domperidone can be regarded as a safe prokinetic and antiemetic agent.

Cyclical vomiting syndrome in a 10 year old girl: a case report

The Sri Lanka Journal of Psychiatry (SLJP) is a peer-reviewed, open access journal published bi annually by the Sri Lanka College of Psychiatrists.The Journal publishes original papers, brief reports including case reports and commentaries relevant to psychiatry and allied sciences. The Sri Lanka Journal of Psychiatry is committed to maintaining and conforming to the editorial and ethical standards recommended by the International Committee of Medical Journal Editors.Cover “Watching and waiting to catch the first rays of dawn, similar to gathering knowledge of psychiatry during my early years of training”. Dr Charani Anuradha Abayaweera, Post-MD Psychiatry trainee

Cyclic Vomiting Syndrome Developed after Stroke

Cyclic vomiting syndrome is characterized by recurrent episodes of stereotyped vomiting separated by regular symptom-free periods. We describe a case of cyclic vomiting syndrome developed after stroke, which has not been reported to date. A 69-year-old woman experienced recurrent vomiting following left cerebral infarct. The patient's vomiting pattern was consistent with cyclic vomiting syndrome, and the diagnosis of cyclic vomiting syndrome was established by exclusion of other known disorders which could have resulted in vomiting. She was treated with imipramine hydrochloride and her symptom was well controlled.